Does the image of this erupting volcano remind you of how it feels in your stomach, chest, or throat sometimes? This article is here to help you understand the mechanics of acid reflux and what you can do about it.
What causes acid reflux and what do you do about it? The answer to these questions is more complicated than any of us would like it to be, but it's worth reading to the end if you've experienced the pain and discomfort of acid reflux, GERD, ulcers, or bile reflux. I've successfully treated a lot of patients with these conditions, so I'll be going over what I've seen work, not work, and the different reasons why people have problems with acid reflux.
What is acid reflux?
Our stomach is the second stage in our complex digestive process, following the first stage that begins with enzymes in our saliva and the physical act of breaking food into smaller pieces by chewing. When the food reaches our stomach, this stage of digestion is dominated by the role of stomach acid. Stomach acid is produced by parietal cells in our stomach lining, and it consists mainly of hydrochloric acid (HCl) with a pH of 1.5 to 3.5 (water is a neutral pH of 7). Our stomach acid plays a crucial role in chemically breaking down food so that we can absorb nutrients from it in the next stage in the small intestine. And that scorchingly low pH also protects us from all manner of food borne pathogens (E.Coli, Salmonella, etc) because we're dropping them into our own personal vat of acid. So without a healthy amount of stomach acid, we can have serious problems with malnutrition (osteoporosis being a common outcome) and contracting gastric pathogens. How does our stomach deal with that extremely acidic environment? Because, like the kids say these days, it's “built different”. Our stomach lining is designed to handle the acidic environment, our other body tissues however - are not.
The most important thing to understand about acid reflux, is that acid reflux is caused by stomach acid in the wrong place - not by too much stomach acid!
There is a valve at the top of the stomach to let food in, and one at the bottom to let food out to the next stage of digestion in our small intestine. The upper valve is called the lower esophageal sphincter (LES for short) and this is what separates our esophagus from our stomach. When the LES malfunctions and does not close properly, stomach acid can migrate up into the esophagus and throat - causing acid reflux and GERD*. The most important thing to understand about acid reflux, is that acid reflux is caused by stomach acid in the wrong place - not by too much stomach acid!
*GERD stands for gastro esophageal reflux disease, and is basically a more technical term to describe this problem - and it’s a bit more accurate since sometimes reflux is not only acid, but also contains digestive enzymes or bile.
Acid-blocking and acid-neutralizing medicines
Most people are under the impression that they have too much stomach acid, because the most popular treatments include acid-blocking medications (proton pump inhibitors or PPIs for short) like omeprazole, Prilosec etc and acid-neutralizing medicines like calcium carbonate (Rolaids, tums) etc. People with acid reflux do not have too much stomach acid, they have acid in the wrong place due to LES dysfunction. Using acid-blocking medications does provide relief for many people. It doesn't fix the lower esophageal sphincter dysfunction, so acid will still make its way up the esophagus, but it reduces the acid production enough that the overall amount of acid available to reflux is reduced to a point where symptoms are reduced.
There is a time and a place for all medications, and that can include proton-pump inhibitors. But it's also very important to understand their risks and limitations. PPIs are not safe for long-term use, and can cause serious problems with malnutrition, causing issues like osteoporosis, as well as contribute to other long term digestive problems and increase the risk of contracting food-borne pathogens. This is plainly written on every box of every PPI, that they are not safe for more than 4 to 8 weeks of continuous use.
So why are they prescribed for decades by doctors ignoring the drug's warning label? Because long term acid reflux is also dangerous. Acid reflux exposes our sensitive tissue in our esophagus to highly corrosive acid, and can cause scarring of the esophagus, which can cause difficulty swallowing, narrowing of the esophagus, and long term inflammation of the tissue can lead to irregular cell growth and potentially esophageal cancer. Yikes!
So it seems like one is stuck between a rock and a hard place if acid-blocking medications were the only option. But they aren't the only option! The mechanisms behind acid reflux are complex and multi-faceted, but it is not rocket science. It honestly boggles my mind that no medications that target improving LES function have made it to market as another pharmaceutical drug treatment for reflux. Fortunately, there are many non-pharmaceutical treatments to address acid reflux - if you know how to approach it.
Demulcent medicines like licorice, marshmallow, and aloe.
I spend a non-zero amount of time on instagram, and in the last few years I have seen a number of supplement companies pop up that have amazing ads where they are explaining acid reflux like they understand it well. As I watch I'm going "nice! finally someone is getting the message out there" as they explain LES function and the importance of healthy stomach acid. Then I look at the product they are selling, and the ingredients indicate that they....don't actually know anything about herbal medicine. And this is more often than not the case. Most supplement companies are run by business experts who don't even bother to hire an herbalist, let alone an herbalist with clinical experience who has worked with real people. They choose product ingredients based on what people will buy, not on what will work.
But back to these products - so they have indicated that they understand LES dysfunction is at the core of acid reflux, but have not included a single herbal medicine to target improving its function. Instead you typically see herbs from the demulcent category - herbs that soothe inflamed tissue. So often I will see aloe, marshmallow, slippery elm, prickly pear as ingredients. In my opinion this whole category of demulcents is not very useful at all, except for licorice - specifically DGL. DGL (Deglycyrrhizinated Licorice) is a very worthy soothing agent so it redeems the category overall. Ingredients like aloe, marshmallow, slippery elm etc can feel good for a short time, but for a lot of people they will worsen reflux in the long term. This is because these mucilaginous herbs form a soothing slime that can coat mucous membranes and temporarily soothe them, but actually take a good amount of work to break down and digest, and can lead to gas and bloating - which can worsen reflux.
DGL on the other hand, does not form the same kind of thick slime yet still helps form a protective coating. It's important to use DGL, rather than straight licorice root because licorice contains a compound, glycyrrhizin, that is fine in small amounts but in large amounts can raise blood pressure to unhealthy levels. In order to use a high enough dose of licorice to utilize its tissue-soothing qualities, this compound has to be removed - as it is in DGL. DGL is a great tool for reducing the damaging effects of reflux, and it should be taken in a chewable tablet form. But soothing tissue is not enough alone, and any "reflux" supplement that is solely using demulcents is not going to be effective. It is essential to simultaneously address the cause of the LES dysfunction.
What causes lower esophageal sphincter dysfunction?
Before we move on to talk about the next category of remedies, we need to better understand the factors that cause LES dysfunction. These are the most common causative factors of LES dysfunction, and people can be primarily dealing with one or several combined. This list is not in order of importance or prevalence.
-insufficient stomach acid
-sympathetic nervous system dominance (too much fight or flight mode)
-hiatal hernia and weak diaphragm
-gas pressure in the upper abdomen / food stagnation
Let's go into these in more detail.
Insufficient stomach acid.
Normal levels of stomach acid are an indicator for our body to close the LES, and when the stomach acid level is too low this can cause the sphincter to not get the signal to close - allowing acid up the esophagus. If the stomach acid is weak, it will also impair the digestive process by not efficiently breaking down food, slowing down our body's process of moving food down and out which can lead to reflux via gas back pressure (more on that later). This is often indicated in people who take acid blocking medications or TUMS and feel worsening of reflux, and conversely in people who feel better when they take a teaspoon of apple cider vinegar before meals.
A common practice prescribed by naturopaths and functional medicine doctors is the "betaine HCl test" where the patient takes betaine HCl, which is essentially synthetic stomach acid, and notes if their reflux improves or worsens. In my experience, this works with a small number of people with relatively mild reflux. These people could probably get away with using apple cider vinegar with meals, and it's easier and safer than betaine HCl. The betaine HCl test doesn't address other important aspects of LES dysfunction, and it's completely inappropriate for anyone with ulceration of the small intestine, stomach, or esophagus. The presence of ulceration can lead to a false negative of this test - where the patient will feel worse because of the ulceration, but that doesn't necessarily indicate that the stomach acid isn't low.
Sympathetic nervous system dominance (too much fight or flight mode)
When we are in a chronic state of stress, our nervous system is predominantly in a sympathetic state, often referred to as "fight or flight". The parasympathetic state is often referred to as the "rest and digest'' state. For reasons obvious in their names, chronic stress interferes with normal digestion. When we feel stressed, often we experience tension in our body. And naturally we might think that a tense body should mean that the lower esophageal sphincter would be tight as a drum, keeping all that stomach acid in check. But this sphincter is a special character, and it actually has the opposite physiologic response - stress makes it relax and lose tone.
Stimulants like caffeine, which contribute to tension and a sympathetic nervous system state, relax and loosen the LES. I can hear you saying "Noooooooooo".... but yes, that's probably the main reason coffee worsens reflux for most people. Tea drinkers are not in the clear either, as any other caffeine is also a potential culprit. Other stimulant drugs like ADHD medications (amphetamine etc) can have similar effects. On the other hand, things that induce parasympathetic tone - where our other body tissues are relaxed - tighten and tones the LES. So reducing stress with exercise, breathing, yoga, meditation techniques etc can be helpful. GABA supplements can also be a supportive tool for improving LES tone via relaxation. Herbs like Peony and Cyperus are especially helpful for this aspect of LES function, found in our Reflux Relief formula (more on that later).
Hiatal hernia and weak diaphragm.
Our diaphragm muscle plays an important role in the function of our lower esophageal sphincter. As you can see in the diagram below, our esophagus passes through a hole in the diaphragm. When everything is good, our stomach and LES stay below the diaphragm and function well. In a hiatal hernia, the LES and upper part of the stomach have migrated above the diaphragm. We can still eat, and breathe etc. But the LES does not function like it's supposed to in this position, and it is more likely to have problems closing and resulting in reflux.
A lot of moms are familiar with hiatal hernias, as a baby growing in the uterus can put pressure on the digestive organs and push the stomach upwards - so hiatal hernias (and related reflux) are common during pregnancy. But hiatal hernias are much more common than just in pregnant women. Poor posture in general, poor posture while eating, and lack of breathing with the diaphragm are very common issues that can result in this problem. When the spine is nice and straight, there is good alignment of the esophagus and diaphragm. When we are sitting forward with the spine hunching over, we are basically squishing on the stomach, and can contribute to causing the LES to be forced above the diaphragm. Eating in a posture like this can make it even more likely to occur. So eating on the couch, in the car, at our desk can all contribute to this problem if we aren't paying attention to our body posture and alignment. Breathing with the diaphragm is important because if the diaphragm muscle is weak and lacking in tone, it's not good at holding the esophagus in the proper place. Most of us do a lot of breathing with our intercostal muscles (in between the ribs) and pectoral muscles, when the diaphragm is our primary breathing muscle. The intercostals, pecs, and scalenes are "accessory" breathing muscles - meaning they should only be backups to the main show. Practicing diaphragmatic breathing aka belly breathing is helpful for addressing and preventing hiatal hernia.
Unlike the other factors that contribute to acid reflux, this one is very much structural. So while some of the herbs in our Reflux Relief to support healthy muscle tone in the diaphragm, it's important to address this factor structurally. Yoga is a great practice for improving body mechanics and breathing simultaneously (check out Yoga with Adriene). A visit to a DO specializing in osteopathic manual manipulation can also be helpful.
Gas pressure in the upper abdomen / food stagnation
In Chinese Medicine we call acid reflux "stomach Qi reversal" because the stomach contents are supposed to be going down, and they are going the wrong way - up! One of the most significant factors that contributes to acid reflux is what we call "food stagnation" in Chinese Medicine. Essentially, this means that the digestive process below the stomach is not functioning well enough to move food down and out at a healthy rate of speed, and the system gets backed up.
In a healthy digestive system, the stomach contents move out of the stomach and into the duodenum (upper part of the small intestine). Here, our gallbladder squirts some bile into the mix which helps break down and emulsify fats so that we can absorb them. Bile is very alkaline (high pH) so it also helps counteract the acidity of the stomach acid-ripened food bolus, which would otherwise be too acidic for the small intestine tissue. In the duodenum the pancreas kicks out digestive enzymes, which help to break down proteins and carbohydrates so that our food can be absorbed in the small intestine. Now the bolus moves into the main small intestine where our body does the majority of its nutrient absorption, on the large intestine where water is absorbed, some additional nutrient absorption occurs, microbial fermentation via our gut flora, and finally the stool is formed and excreted.
There are many players in the digestive process, and even a small decrease in function from one player can affect the whole system. If the digestive process slows down, the food bolus doesn't move through fast enough and that means there isn't room for more food to come down the pipe. One of the most common issues is that when the food bolus is sitting in the small intestine too long, microbial fermentation begins. Gas is a natural byproduct of microbes doing their job, but that is supposed to be happening primarily in the large intestine, where the gas generated will have the easiest route passing out our rear end. When the gas is generated by fermentation in too high up in our small intestine, its fastest route out the body is by exiting through our mouth in the form of a burp. Any belching (aside from drinking highly carbonated drinks) is a sign of stomach Qi reversal and a sign that our digestive process isn't moving along like it should. This gas pressure in the upper abdomen puts upward pressure on the stomach organ, and can push the stomach contents - most importantly stomach acid - up into the esophagus.
What can go wrong to result in food stagnation? If the stomach acid is weak, the bolus hasn't been properly broken down and now the rest of the system has to work overtime to do the job. If the gallbladder is congested or clogged with sludge or stones, or simply overburdened by an excess of fat-rich foods - it won't contribute enough bile to the process. If the pancreas isn't producing adequate digestive enzymes, the food bolus won't be broken down properly. And then there's the intestinal peristalsis, or migrating motor complex, that pushes the food along down the line with many small successive contractions of small muscles - like the way a snake moves. Our intestinal peristalsis is generally supported by contractions of larger abdominal muscles, which would typically happen in everyday movements like walking around. Modern times and modern jobs have us much more sedentary than we should be, and this contributes to poor digestive function. As does eating meals that are too large or too rich for our digestive system to handle at one time.
Microbiome Dysbiosis & baddies like H. pylori and Candida albicans
Another important factor that impacts the proper movement of food through our digestive system is the ecosystem of microbes that exists within us. Referred to as our microbiome, this ecosystem consists of a diverse community of bacteria, fungi, viruses, and yeasts with a population roughly equal to the number of human cells in our body. A vast amount of these microbes live in our digestive tract. As in all ecosystems, there are a variety of relationships - commensal, symbiotic, parasitic, etc. In simpler terms, some organisms do helpful things for the human organism and some of them do rather unhelpful things for us.
Dysbiosis refers to the state when the balance or organisms has shifted towards a preponderance of parasitic or pathogenic organisms that cause problems for us. Dysbiosis can come about from overuse of antibiotics, excessive sugar consumption in the diet, bad luck in encountering food borne pathogens or parasites, or a variety of other avenues. Dysbiosis can contribute to problems with intestinal peristalsis, and to over-production of gas - both of which can contribute to acid reflux. Successfully addressing dysbiosis is often accomplished through gentle and broad spectrum antimicrobial herbs, introduction of beneficial bacteria via probiotics, and dietary therapy to reduce feeding the pathogenic organisms.
If we eat a high sugar/carb diet we will support the proliferation of certain microbes, like the yeast Candida for example. If our stomach acid is weak, we are more likely to contract bacteria like Heliobacter pylori - which can infect the stomach and small intestine lining, creating ulcers and contributing to acid reflux patterns. It can hard to pinpoint exactly which bad actors in our microbial ecosystem might be causing us problems, so I find it better to think in terms of the overall big picture and trend. Bacteria and yeast/fungi aren't really good or bad, but there are certainly ones that tend to be most likely to cause problems in human biomes. Most of these "baddies" will proliferate on a high sugar/carb diet. And they will be gently suppressed by herbs like Perilla, Pogostemon, Scuttelaria, and Coptis in Reflux Relief.
Any bacteria or yeast that colonizes the upper small intestine - even the classically "pro" biotics can cause problems with gas pressure and bloating. This is one reason that healthy peristalsis is so important, so that microbes from the large intestine don't migrate the wrong way up into the small intestine. And it's also a reason that recommendations for probiotics in acid reflux patterns can be tough. I'll admit that the world of probiotics seemed to be a lot simpler 10 years ago when some kimchi and L. acidophilus seemed to be enough. Spore-based or Soil-Based Organism probiotics may be better choices in reflux patterns.
It is absolutely true that probiotic supplements can benefit a wide range of conditions, but acid reflux is one area where they sometimes make it worse. That doesn't mean it's not worth trying some, but I do recommend paying attention to if things are trending better or worse. My current thought is that they are likely beneficial in mild reflux patterns, or in the later stages of treatment for people with moderate to severe reflux, after problems with sphincter function and peristalsis have been addressed.
Bile reflux
This is not the main subject of this article, but very much related - so I wanted to include some discussion of bile reflux as well. From what I have gathered working with patients with bile reflux, it can be a special kind of hell. With bile reflux, both the pyloric sphincter (the valve leading from the stomach into the duodenum) and the lower esophageal sphincter are not functioning well - so stomach acid, food, and bile that was secreted from the gallbladder all go the wrong way (up!) and end up in the esophagus. Acid can damage mucous membranes due to its low pH, but the very high alkaline pH of bile is also very damaging to tissue. Bile reflux tends to cause more severe damage and pain in the esophagus faster than acid reflux does.
Fortunately, all of what we covered relating to acid reflux also pertains to bile reflux. Focusing on sphincter function, improving peristalsis so food goes down instead of up, and improving the overall function of our digestive organs is what we do. I have used our Reflux Relief formula with bile reflux in the clinic with success, but I have often found it necessary to add other herbs that target the gallbladder more specifically. Most of the people I have worked with were told that their tests indicated their gallbladders were working in excess, and producing an unusually large quantity of bile. My experience is that their gallbladders may have been producing an excess of bile (that seemed to be empirically true), but the organ was not over-functioning. When given herb formulas that improve the gallbladder function, and actually increase bile secretion, their bile reflux symptoms improved. My hypothesis is that what's happening is that the gallbladder is congested with sludge or small stones, and is producing more bile to try to expel and dissolve the gunk. And that happens to pair unfortunately with sphincter dysfunction and poor peristalsis and results in painful bile reflux. Again, not really a problem of too much bile - but of bile in the wrong place.
Now, what do we do about it all?
So now we understand that the factors involved in lower esophageal dysfunction are complex. So let's talk more about what to do about them.
Deficiency of digestive enzymes. A simple way to support our digestive system when our pancreas isn't producing enough digestive enzymes is to add more to the tank. I prefer simple enzymes like chewable papaya enzymes and this enzyme complex, though many will work. I don't recommend you use one with ox bile, unless you are purposely wanting to use ox bile (more on that later). Enzymes that support FODMAP digestion can be helpful for a lot of folks where high FODMAP foods contribute to upper abdominal gas (also more on that later). Rather than rely on taking external enzymes, for long term resolution I prefer to use herbs that stimulate and strengthen our own bodies ability to produce digestive enzymes. That's why we use herbs like ginger, Atractylodes, and cardamom in our Reflux Relief formula.
Gallbladder dysfunction. When the gallbladder is congested or under functioning, there are several ways to support it. Ox Bile or bile salts is one way. This is similar to taking external digestive enzymes, you are adding external bile to support digestion when our gallbladder isn't up the task. In my experience it's best to use small doses (125 mg not 500 mg) at a time, and it's very important to take it with food, specifically eat a good amount of food after taking the capsule. Acid burns our mucosa with its low pH, bile also burns our mucosa with its very high pH, you don't want that capsule opening up in your esophagus which can happen if you take it and don't follow it with food to push it down. It should also be taken with fat-containing meals, and generally not if you are just eating an apple, for example. As with enzymes, I generally prefer to use herbal medicines which stimulate the gallbladder to function better. In our Reflux Relief formula we use bitter orange, scutelleria, and coptis to stimulate gallbladder function. Many digestive bitters formulas contain good bile stimulating herbs, some of my favorite being artichoke leaf.
*If you have had your gallbladder removed, your GI doctor should have told you to take ox bile/bile salts with fatty meals - but most of them do not. Without a gallbladder, your liver still produces bile but instead of the gallbladder storing it up and releasing it in response to eating fat, your body will just drip bile into your duodenum at a slow and constant rate. This means that you will not be able to emulsify and break down fats without an external source timed with meals. Typically this will result in loose stool or constipation from eating fatty foods, but I've also seen it contribute to a variety of other health issues.
Digestive bitters.
What are digestive bitters, you ask? Digestive bitters are one of the best home remedies for supporting healthy digestion. They are typically made in a tincture form, an alcohol extraction of herbal medicines, though you will find some that come as a glycerin extract. Digestive bitters are taken before or after meals to stimulate our body's digestive process by stimulating enzyme, bile, and stomach acid secretion. Digestive bitters are unique because they tend to use a low dose of herbal medicines, and much of the action happens when the bitter flavors activate taste receptors in our mouth - which signals to our digestive organs to "get to work!" but, like in a nice way.
Historically, digestive bitters came about as our diet shifted to include less and less bitter foods, and more just sweet, fat, and salt. People began having more digestive issues, because these bitter foods serve important roles in our health and digestion, and so started taking little doses of bitters via herbs. Adding digestive bitters to a pre or post meal cocktail created the original apertif and digestif - a medicinal infusion combined with an alcoholic drink to support digestion and catch a buzz at the same time. Today, the wide variety of "cocktail bitters" may or may not have an effective digestive impact because they used to be formulated by herbalists aka old time doctors, and over time that shifted to people turning any random plant with a bitter flavor into a type of "drink bitters."
Digestive bitters are not all created equal, and how well they work is going to be entirely based on which herbs have been chosen in the formula and how well that formula matches an individual's digestion pattern. We categorize herbs in bitters as "cold bitters" and "warming bitters" and for the average person, a formula that includes both cold and warming herbs will yield the best results. So I tend to recommend bitters formulas that have an overall balanced formulation, and advise against using bitters that have a heavy weight towards cold bitters. That means no cold purgative herbs like rhubarb, senna, cape aloe, etc. I do not like Swedish bitters one bit, for example. These are some of my favorite digestive bitters - Herb Pharm Bitters. And of course, bitter herbs like bitter orange, coptis, and scutellaria are used in our Reflux Relief to stimulate these actions, but from a water extraction not an alcohol extraction.
Diet: you can't always get what you want, but you always get what you need
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